Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use

School based education programme to reduce salt intake in children and their families (School-EduSalt): cluster randomised controlled trial

OBJECTIVE

To determine whether an education programme targeted at schoolchildren could lower salt intake in children and their families.

DESIGN

Cluster randomised controlled trial, with schools randomly assigned to either the intervention or control group.

SETTING

28 primary schools in urban Changzhi, northern China.

PARTICIPANTS

279 children in grade 5 of primary school, with mean age of 10.1; 553 adult family members (mean age 43.8).

INTERVENTION

Children in the intervention group were educated on the harmful effects of salt and how to reduce salt intake within the schools' usual health education lessons. Children then delivered the salt reduction message to their families. The intervention lasted for one school term (about 3.5 months).

MAIN OUTCOME MEASURES

The primary outcome was the difference between the groups in the change in salt intake (as measured by 24 hour urinary sodium excretion) from baseline to the end of the trial. The secondary outcome was the difference between the two groups in the change in blood pressure.

RESULTS

At baseline, the mean salt intake in children was 7.3 (SE 0.3) g/day in the intervention group and 6.8 (SE 0.3) g/day in the control group. In adult family members the salt intakes were 12.6 (SE 0.4) and 11.3 (SE 0.4) g/day, respectively. During the study there was a reduction in salt intake in the intervention group, whereas in the control group salt intake increased. The mean effect on salt intake for intervention versus control group was -1.9 g/day (95% confidence interval -2.6 to -1.3 g/day; P<0.001) in children and -2.9 g/day (-3.7 to -2.2 g/day; P<0.001) in adults. The mean effect on systolic blood pressure was -0.8 mm Hg (-3.0 to 1.5 mm Hg; P=0.51) in children and -2.3 mm Hg (-4.5 to -0.04 mm Hg; P<0.05) in adults.

CONCLUSIONS

An education programme delivered to primary school children as part of the usual curriculum is effective in lowering salt intake in children and their families. This offers a novel and important approach to reducing salt intake in a population in which most of the salt in the diet is added by consumers.Trial registration ClinicalTrials.gov NCT01821144. .

Sociodemographic, psychological, and lifestyle characteristics are associated with a liking for salty and sweet tastes in French adults

BACKGROUND

Various studies have shown that sensory liking influences dietary behavior and that individual characteristics are related to food intake and weight status, but little is known about individual profiles associated with salt and sweet liking.

OBJECTIVE

The aim of the present study was to investigate the association between a liking for salty and sweet tastes (i.e., a liking for foods rich in salt or sugar and preferred amounts of salt or sugar seasoning in foods) and sociodemographic, psychological, and lifestyle characteristics in a large sample.

METHODS

Individual factors and liking scores were collected by validated questionnaires from 37,181 French adults participating in the NutriNet-Santé study, a large web-based observational cohort launched in 2009 that studies relations between nutrition and health. The associations were assessed by multivariable multinomial logistic regression models adjusted for socioeconomic, anthropometric, and health variables.

RESULTS

In both genders, with increasing age, individuals were more likely to have a high salt liking (men, OR: 1.24; 95% CI: 1.18, 1.30; women, OR: 1.14, 95% CI: 1.09, 1.19), whereas they were less likely to have a strong sweet liking (men, OR: 0.87; 95% CI: 0.83, 0.91; women, OR: 0.66; 95% CI: 0.64, 0.68). Current smokers (men, OR: 2.30; 95% CI: 1.90, 2.78; women, OR: 1.50; 95% CI: 1.36, 1.66) and heavy drinkers (men, OR: 2.92; 95% CI: 2.37, 3.58; women, OR: 2.57, 95% CI: 2.22, 2.98) were more likely to like salt than nonsmokers and alcohol abstainers. Regarding the sweet taste, women smokers were less likely to like sweets (OR: 0.80; 95% CI: 0.72, 0.89). Highly uncontrolled eaters [men, OR: 2.39; 95% CI: 2.04, 2.80; women, OR: 2.22; 95% CI: 1.99, 2.47) and highly emotional women (OR: 1.35; 95% CI: 1.18, 1.55) were more likely to have a high liking for sweets than slightly uncontrolled eaters and nonemotional eaters, whereas those with high cognitive restraint (men, OR: 0.39; 95% CI: 0.33, 0.46; women, OR: 0.55; 95% CI: 0.50, 0.60) and former weight-loss dieters (men, OR: 0.60; 95% CI: 0.52, 0.70; women, OR: 0.68; 95% CI: 0.62, 0.73) were less likely to have a strong sweet liking compared with those with low cognitive restraint and never-dieters.

CONCLUSION

An unhealthy lifestyle that includes smoking and alcohol consumption may influence salt liking, and eating behavior may have an impact on sweet liking. Further research is needed to study the influence of individual factors and sensory liking on dietary intake and weight status. This study was registered at the European Clinical Trials Database as 2013-000929-31.

Salt and sugar: their effects on blood pressure

Both dietary salt and sugar are related to blood pressure (BP). The evidence for salt is much stronger, and various types of studies have consistently shown that salt is a major cause of raised BP, and a reduction from the current intake of ≈ 9-12 g/day in most countries of the world to the recommended level of 5-6 g/day lowers BP in both hypertensive and normotensive individuals, in men and women, in all age groups and in all ethnic groups. Countries such as Finland and the UK that have successfully reduced salt intake have demonstrated a reduction in population BP and cardiovascular mortality, with major cost savings to the health service. The mechanisms whereby salt raises BP are not fully understood. The traditional concepts focus on the tendency for an increase in extracellular fluid volume. Increasing evidence suggests that small increases in plasma sodium may play an important role. There are several other factors that also increase BP, one of which is added sugars. The current high intake of added sugars increases obesity which, in turn, raises BP. Recent studies also suggest that added sugars, particularly those in soft drinks, may have a direct effect on BP. However, the relationship between soft drink consumption and BP could be, at least partially, mediated by the effect of salt intake on increasing soft drink consumption. Actions to reduce salt and sugar intake across the whole population will have major beneficial effects on health along with major cost savings.

Sodium intake in US ethnic subgroups and potential impact of a new sodium reduction technology: NHANES Dietary Modeling

BACKGROUND

Because excessive dietary sodium intake is a major contributor to hypertension, a reduction in dietary sodium has been recommended for the US population. Using the National Health and Nutrition Examination Survey (NHANES) 2007-2010 data, we estimated current sodium intake in US population ethnic subgroups and modeled the potential impact of a new sodium reduction technology on sodium intake.

METHODS

NHANES 2007-2010 data were analyzed using The National Cancer Institute method to estimate usual intake in population subgroups. Potential impact of SODA-LO® Salt Microspheres sodium reduction technology on sodium intake was modeled using suggested sodium reductions of 20-30% in 953 foods and assuming various market penetrations. SAS 9.2, SUDAAN 11, and NHANES survey weights were used in all calculations with assessment across age, gender and ethnic groups.

RESULTS

Current sodium intake across all population subgroups exceeds the Dietary Guidelines 2010 recommendations and has not changed during the last decade. However, sodium intake measured as a function of food intake has decreased significantly during the last decade for all ethnicities. "Grain Products" and "Meat, Poultry, Fish, & Mixtures" contribute about 2/3rd of total sodium intake. Sodium reduction, using SODA-LO® Salt Microspheres sodium reduction technology (with 100% market penetration) was estimated to be 185-323 mg/day or 6.3-8.4% of intake depending upon age, gender and ethnic group.

CONCLUSIONS

Current sodium intake in US ethnic subgroups exceeds the recommendations and sodium reduction technologies could potentially help reduce dietary sodium intake among those groups.

Progress on salt reduction in the Pacific Islands: from strategies to action

BACKGROUND

Most populations are consuming too much salt which is the main contributor of high blood pressure, a leading risk factor of cardiovascular disease and stroke. The South Pacific Office of the World Health Organization has been facilitating the development of salt reduction strategies in Pacific Island Countries and areas (PICs). The objective of this analysis was to review progress to date and identify regional actions needed to support PICs and ensure they achieve the global target to reduce population salt intake by 30% by 2025.

METHODS

Relevant available national food, health and non-communicable disease (NCD) plans from all 22 PICs were reviewed. NCD co-ordinators provided updates and relayed experiences through semi-structured interviews. All activities were systematically categorised according to an existing salt reduction framework for the development of salt reduction strategies.

RESULTS

Salt reduction consultations had been held in 14 countries and final strategies or action plans developed in nine of these, with drafts available in a further three. Three other countries had integrated salt reduction into NCD strategic plans. Baseline monitoring of salt intake had been undertaken in three countries, salt levels in foods in nine countries and salt knowledge, attitude and behaviour surveys in four countries. Most countries were at early stages of implementation and identified limited resources as a barrier to action. Planned salt reduction strategies included work with food industry or importers, implementing regional salt reduction targets, reducing salt levels in school and hospital meals, behaviour change campaigns, and monitoring and evaluation.

CONCLUSIONS

There had been good progress on salt reduction planning in PICs. The need for increased capacity to effectively implement agreed activities, supported by regional standards and the establishment of improved monitoring systems, were identified as important steps to ensure the potential cardiovascular health benefits of salt reduction could be fully realised in the region.

Deaths ascribed to non-communicable diseases among rural Kenyan adults are proportionately increasing: evidence from a health and demographic surveillance system, 2003-2010

BACKGROUND

Non-communicable diseases (NCDs) result in more deaths globally than other causes. Monitoring systems require strengthening to attribute the NCD burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal.

METHODS AND FINDINGS

Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya, attributed into broad categories using InterVA-4 computer algorithms; 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% (39% male, 48% female) of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010 (χ2 linear trend 93.4; p<0.001). While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. The substantial fall in CD MRs resulted in similar MRs for CDs and NCDs among all adult females by 2010. NCD MRs for adults aged 15y to <65y fell from 409 to 183 per 100,000 among females and from 517 to 283 per 100,000 population among males. NCD MRs were higher among males than females aged both below, and at or above, 65y.

CONCLUSIONS

NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.

Need for better blood pressure measurement in developing countries to improve prevention of cardiovascular disease

Hypertension is now the foremost cause of disability and is responsible for the highest percentage of attributable death among risk factors. These global changes are mainly due to the increase in the prevalence of hypertension in most low- and middle-income countries (LMICs) as a consequence of relevant socioeconomic changes occurring during the last decades. Implementation of global prevention efforts urgently needs to be accelerated because of the increasing incidence of haemorrhagic stroke, renal failure, and hypertensive heart disease in developing countries. Blood pressure (BP) measurement has different implications in epidemiological studies performed in low-resource settings. First, the frequency of blood pressure measurement is a simple but reliable indicator of access to healthcare in epidemiological studies, which may disclose the favourable effects of urbanization; the opportunity to have BP measured increases hypertension awareness, facilitates drug treatment, and leads to better achievement of BP control. Second, BP measurement is a key element in cardiovascular risk stratification, focusing solely on the preferred strategy in low-resource settings where costs of biochemical tests might be less sustainable. Third, the issue of obtaining reliable estimation of BP values is crucial to achieve sound data on the burden of hypertension in LMICs, and some aspects of BP measurement, such as the use of reliable automated devices, the number of measurements/visits to achieve a consistent diagnosis of hypertension, and the possible confounding effect of environmental factors, must be closely considered.

High prevalence of substance use and associated factors among high school adolescents in Woreta Town, Northwest Ethiopia: multi-domain factor analysis

BACKGROUND

Substance use is a major public health concern in global settings, and is very common during adolescence period leading to physical and/or mental health complications. This study assessed the prevalence of substance use and associated factors among high school adolescents in Woreta Town, Northwest Ethiopia, 2012.

METHODS

A school based cross-sectional study was conducted from April 7 to April 15, 2012 amongst 684 9th to 12th grade high school students in the town of Woreta. Participants were selected by stratified sampling, and data were collected using an anonymous questionnaire adapted from the 2008 Community That Care Youth Survey. Bivariate and multivariate logistic regression analysis was performed to identify factors associated with substance use.

RESULTS

A total of 651 students participated in the study with a response rate of 95.2%. The current prevalence of substance use among Woreta high school students was 47.9% and life-time prevalence was 65.4%. The current and lifetime prevalence of alcohol use was 40.9% and 59% respectively. Siblings' use of substances (AOR [95% CI]: 2.72 [1.79, 4.14]), family history of alcohol and substance use (AOR [95% CI] 2.24 [1.39-3.59]) and friends' use of substances (AOR [95% CI] 2.14 [1.44-3.18]) were factors positively associated with substance use. On the other hand, religiosity and social skill were found to be 54% (AOR [95% CI] 0.46, [0.31-0.68]) and 39% (AOR [95% CI] 0.6 [0.40-0.91]) negatively associated with substance use.

CONCLUSIONS

The prevalence of substance use amongst adolescents was high for the three substances namely alcohol, cigarette and khat with alcohol being the most common. Community norms favorable to substance use, family history of alcohol and substance use, siblings' substance use, poor academic performance, low perceived risk of substances and friends' use of substances had positive association with adolescent substance use while religiosity and social skills were found to have negative association with adolescent substance use. Initiate public awareness campaigns to inform adolescents and adults, particularly parents, of the risk of substance use. Developing culture friendly, gender based adolescent and family based programs and initiating public awareness are recommended to decrease substance use by adolescents.

Evidence for cost-effectiveness of lifestyle primary preventions for cardiovascular disease in the Asia-Pacific Region: a systematic review

Background

Countries of the Asia Pacific region account for a major share of the global burden of disease due to cardiovascular disease (CVD) and this burden is rising over time. Modifiable behavioural risk factors for CVD are considered a key target for reduction in incidence but their effectiveness and cost-effectiveness tend to depend on country context. However, no systematic assessment of cost-effectiveness of interventions addressing behavioural risk factors in the region exists.

Methods

A systematic review of the published literature on cost-effectiveness of interventions targeting modifiable behavioural risk factors for CVD was undertaken. Inclusion criteria were (a) countries in Asia and the Pacific, (b) studies that had conducted economic evaluations of interventions (c) published papers in major economic and public health databases and (d) a comprehensive list of search words to identify appropriate articles. All authors independently examined the final list of articles relating to methodology and findings.

Results

Under our inclusion criteria a total of 28 studies, with baseline years ranging from 1990 to 2012, were included in the review, 19 conducted in high-income countries of the region. Reviewed studies assessed cost-effectiveness of interventions for tobacco control, alcohol reduction, salt intake control, physical activity and dietary interventions. The majority of cost-effectiveness analyses were simulation analyses mostly relying on developed country data, and only 6 studies used effectiveness data from RCTs in the region. Other than for Australia, no direct conclusions could be drawn about cost-effectiveness of interventions targeting behavioural risk factors due to the small number of studies, interventions that varied widely in design, and varied methods for measurement of costs associated with interventions.

Conclusions

Good quality cost-effectiveness information on interventions targeting behavioural interventions for the Asia-Pacific region remains a major gap in the literature.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-014-0079-3) contains supplementary material, which is available to authorized users.

Salt as a public health challenge in continental European convenience and ready meals

OBJECTIVE

To assess the salt content of continental European convenience and ready meals.

DESIGN

A multistage study in which, after laboratory analysis of the products' salt contents (n 32), new salt-reduced meals were developed through food reformulation. Additionally, a comprehensive survey of convenience meals from the Austrian market (n 572) was conducted to evaluate the salt contents of a wider product range.

SETTING

Six continental European countries participated.

SUBJECTS

No subjects enrolled.

RESULTS

The salt contents of continental European convenience and ready meals mostly exceeded 1·8 g/100 g, which is 30 % of the targeted daily intake level; some contained even more than the recommended daily intake of 6 g. The highest salt contents were found in pizzas and pasta dishes, the lowest ones in sweet meals. Large variations in salt levels were found not only between and within meal type categories, but also between similar meals from different producers. In addition, our approach to develop new salt-reduced meals showed that a stepwise reduction of the ready meals' salt contents is possible without compromising the sensory quality.

CONCLUSIONS

To address the problem of hypertension and increased risk for CVD through high salt intake, a reduction of the salt levels in continental European convenience and ready meals is urgently needed, since they are providing a major part of the daily salt intake. Successful national-wide salt reduction strategies in the UK or Finland have already demonstrated the public health impact of this setting.

Protocol for developing the evidence base for a national salt reduction programme for India

INTRODUCTION

The scientific evidence base in support of salt reduction is strong but the data required to translate these insights into reduced population salt intake are mostly absent. The aim of this research project is to develop the evidence base required to formulate and implement a national salt reduction programme for India.

METHODS AND ANALYSIS

The research will comprise three components: a stakeholder analysis involving government, industry, consumers and civil society organisations; a population survey using an age-stratified and sex-stratified random samples drawn from urban (slum and non-slum) and rural areas of North and South India; and a systematic quantitative evaluation of the nutritional components of processed and restaurant foods. The stakeholder interviews will be analysed using qualitative methods to summarise the main themes and define the broad range of factors influencing the food environment in India. The population survey will estimate the mean daily salt consumption through the collection of 24 h urine samples with concurrent dietary surveys identifying the main sources of dietary sodium/salt. The survey of foods will record the nutritional composition of the chief elements of food supply. The findings from this research will be synthesised and proposals for a national salt reduction strategy for India will be developed in collaboration with key stakeholders.

ETHICS AND DISSEMINATION

This study has been approved by the Human Research Ethics Committees of the University of Sydney and the Centre for Chronic Disease Control in New Delhi, and also by the Indian Health Ministry's Screening Committee. The project began fieldwork in February 2014 and will report the main results in 2016. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities.

Sources and correlates of sodium consumption in the first 2 years of life

BACKGROUND

High sodium intake during infancy and early childhood can change salt preference and blood pressure trajectories across life, representing a modifiable cardiovascular risk factor. Describing young children's sodium intake is important for informing effective targets for sodium reduction.

OBJECTIVE

This study aimed to describe food sources and demographic and behavioral correlates of sodium intake in 295 young Australian children using three unscheduled 24-hour recalls (when children were 9 and then 18 months of age) with mothers participating within an existing randomized controlled trial, the Melbourne Infant Feeding Activity and Nutrition Trial (InFANT) Program.

METHODS

Differences in individual-level and family-level demographic and behavioral variables were assessed across tertiles of sodium density (mg/1,000 kcal). Descriptive statistics were used to describe food-group contributions to total energy and sodium intakes at both ages.

RESULTS

Mean sodium intake was 486 mg (standard deviation=232 mg) at 9 months and had more than doubled to 1,069 mg (standard deviation=331 mg) at 18 months of age. Fifty-four percent of children at 18 months exceeded the Recommended Daily Upper Level for sodium intake, with bread, cheese, breakfast cereal, soup, and mixed dishes all important sources of sodium at both ages. Yeast extracts, processed meats, and bread products became important additional sources at 18 months. A greater proportion of children in the highest sodium-density tertile had ceased breastfeeding and had commenced solids at an earlier age.

CONCLUSIONS

The key food sources of sodium for children younger than 2 years are those that contribute to the whole population's high salt burden and highlight the essential role governments and food industry must play to reduce salt in commonly consumed foods.

To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs

The World Health Organization promotes salt reduction as a best-buy strategy to reduce chronic diseases, and Member States have agreed to a 30% reduction target in mean population salt intake by 2025. Whilst the UK has made the most progress on salt reduction, South Africa was the first country to pass legislation for salt levels in a range of processed foods. This paper compares the process of developing salt reduction strategies in both countries and highlights lessons for other countries. Like the UK, the benefits of salt reduction were being debated in South Africa long before it became a policy priority. Whilst salt reduction was gaining a higher profile internationally, undoubtedly, local research to produce context-specific, domestic costs and outcome indicators for South Africa was crucial in influencing the decision to legislate. In the UK, strong government leadership and extensive advocacy activities initiated in the early 2000s have helped drive the voluntary uptake of salt targets by the food industry. It is too early to say which strategy will be most effective regarding reductions in population-level blood pressure. Robust monitoring and transparent mechanisms for holding the industry accountable will be key to continued progress in each of the countries.

Consumer detection and acceptability of reduced-sodium bread

OBJECTIVE

Bread is the largest contributor of Na to the American diet and excess Na consumption contributes to premature death and disability. We sought to determine the Na level at which consumers could detect a difference between reduced-Na bread and bread with typical Na content, and to determine if consumer sensory acceptability and purchase intent differed between reduced-Na bread and bread with typical Na content.

DESIGN

Difference testing measured ability to detect differences in control bread and reduced-Na bread using two-alternative forced choice testing. Acceptability was measured using a nine-point hedonic scale and purchase intent was measured using a five-point purchase intent scale.

SETTING

Difference and acceptability testing were conducted in Portland, OR, USA in January 2013.

SUBJECTS

Eighty-two consumers participated in difference testing and 109 consumers participated in acceptability testing.

RESULTS

Consumers did not detect a difference in saltiness between the control bread and the 10 % reduced-Na bread, but did detect a difference between the control bread and bread reduced in Na content by 20 % and 30 %. Na reductions had no effect on consumer acceptability of sensory characteristics, including overall liking, appearance, aroma, flavour, sweetness, salt level and texture, or purchase intent.

CONCLUSIONS

Reducing Na levels by up to 30 % in the sandwich bread tested did not affect consumer liking or purchase intent of the product. These results support national recommendations for small, incremental Na reductions in the food supply over time and assure bread manufacturers that sensory characteristics and consumer purchase intent of their products will be preserved after Na reductions occur.

Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods

Reducing population salt intake has been identified as a priority intervention to reduce non-communicable diseases. Member States of the World Health Organization have agreed to a global target of a 30% reduction in salt intake by 2025. In countries where most salt consumed is from processed foods, programs to engage the food industry to reduce salt in products are being developed. This paper provides a comprehensive overview of national initiatives to encourage the food industry to reduce salt. A systematic review of the literature was supplemented by key informant questionnaires to inform categorization of the initiatives. Fifty nine food industry salt reduction programs were identified. Thirty eight countries had targets for salt levels in foods and nine countries had introduced legislation for some products. South Africa and Argentina have both introduced legislation limiting salt levels across a broad range of foods. Seventeen countries reported reductions in salt levels in foods—the majority in bread. While these trends represent progress, many countries have yet to initiate work in this area, others are at early stages of implementation and further monitoring is required to assess progress towards achieving the global target.

Distribution and determinants of non communicable diseases among elderly Uyghur ethnic group in Xinjiang, China

Background

Non-communicable diseases (NCDs) are showing an increasing trend globally as well as in China. Elderly population are more prone to these NCDs. Situation in China is worse owing to the higher proportion of geriatric population. Burden of NCDs and the role of their socio-demographic and behavioral predictors among these elderly and more so among the ethnic minority groups among them, need to be investigated specifically, owing to their distinct genetic background, lifestyles and behavior.

Methods

A cross-sectional study was conducted among 1329 randomly selected persons of Uyghur ethnicity, aged 60 years or more in Xinjiang, the largest administrative division in China to measure the burden of NCDs, understand the distribution of socio-demographic, behavioral and life event-related potential correlates of them and to estimate the association of the NCDs with these correlates.

Results

Among these participants 54.2% were female, 86.8% were married and more than half had only attended elementary school or less. 41.46% was suffering from at least one NCD. 20.22% had one NCD, 12.11% had two and 8.58% had three or more. 27.3% had hypertension, 4.06% had diabetes, 6.02% had hyperlipidemia, 7.37% had angina, 14.52% had cardiovascular diseases, 11.59% had any kind of cancers and 9.78% had chronic obstructive pulmonary diseases. Rural residents (OR = 1.45, 95% CI: 1.17–1.80, AOR = 2.00, 95% CI: 1.53–2.61) and current smokers had higher odds of having more NCDs (AOR = 1.53, 95% CI: 1.00–2.34). Additionally not being satisfied with current life, not being able to take care of self in daily life, currently not being involved in farm work, less intake of fresh vegetables, fruits and garlic, too less or too much salt intake, not having hobbies were found to be positively associated with having more NCDs.

Conclusion

Implementation of effective intervention strategies to promote healthy life styles among the Uyghur elderly population of China seems urgent.

Vegan diet, subnormal vitamin B-12 status and cardiovascular health

Vegetarian diets have been associated with atherosclerosis protection, with healthier atherosclerosis risk profiles, as well as lower prevalence of, and mortality from, ischemic heart disease and stroke. However, there are few data concerning the possible cardiovascular effects of a vegan diet (with no meat, dairy or egg products). Vitamin B-12 deficiency is highly prevalent in vegetarians; this can be partially alleviated by taking dairy/egg products in lact-ovo-vegetarians. However, metabolic vitamin B-12 deficiency is highly prevalent in vegetarians in Australia, Germany, Italy and Austria, and in vegans (80%) in Hong Kong and India, where vegans rarely take vitamin B-12 fortified food or vitamin B-12 supplements. Similar deficiencies exist in northern Chinese rural communities consuming inadequate meat, egg or dairy products due to poverty or dietary habits. Vascular studies have demonstrated impaired arterial endothelial function and increased carotid intima-media thickness as atherosclerosis surrogates in such metabolic vitamin B-12 deficient populations, but not in lactovegetarians in China. Vitamin B-12 supplementation has a favourable impact on these vascular surrogates in Hong Kong vegans and in underprivileged communities in northern rural China. Regular monitoring of vitamin B-12 status is thus potentially beneficial for early detection and treatment of metabolic vitamin B-12 deficiency in vegans, and possibly for prevention of atherosclerosis-related diseases.

Global sodium consumption and death from cardiovascular causes

BACKGROUND

High sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain.

METHODS

We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries (accounting for 74.1% of adults throughout the world), and we used these data to quantify the global consumption of sodium according to age, sex, and country. The effects of sodium on blood pressure, according to age, race, and the presence or absence of hypertension, were calculated from data in a new meta-analysis of 107 randomized interventions, and the effects of blood pressure on cardiovascular mortality, according to age, were calculated from a meta-analysis of cohorts. Cause-specific mortality was derived from the Global Burden of Disease Study 2010. Using comparative risk assessment, we estimated the cardiovascular effects of current sodium intake, as compared with a reference intake of 2.0 g of sodium per day, according to age, sex, and country.

RESULTS

In 2010, the estimated mean level of global sodium consumption was 3.95 g per day, and regional mean levels ranged from 2.18 to 5.51 g per day. Globally, 1.65 million annual deaths from cardiovascular causes (95% uncertainty interval [confidence interval], 1.10 million to 2.22 million) were attributed to sodium intake above the reference level; 61.9% of these deaths occurred in men and 38.1% occurred in women. These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes (9.5%). Four of every 5 deaths (84.3%) occurred in low- and middle-income countries, and 2 of every 5 deaths (40.4%) were premature (before 70 years of age). The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya.

CONCLUSIONS

In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day. (Funded by the Bill and Melinda Gates Foundation.).

Socioeconomic inequality in salt intake in Britain 10 years after a national salt reduction programme

OBJECTIVES

The impact of the national salt reduction programme in the UK on social inequalities is unknown. We examined spatial and socioeconomic variations in salt intake in the 2008-2011 British National Diet and Nutrition Survey (NDNS) and compared them with those before the programme in 2000-2001.

SETTING

Cross-sectional survey in Great Britain.

PARTICIPANTS

1027 Caucasian males and females, aged 19-64 years.

PRIMARY OUTCOME MEASURES

Participants' dietary sodium intake measured with a 4-day food diary. Bayesian geo-additive models used to assess spatial and socioeconomic patterns of sodium intake accounting for sociodemographic, anthropometric and behavioural confounders.

RESULTS

Dietary sodium intake varied significantly across socioeconomic groups, even when adjusting for geographical variations. There was higher dietary sodium intake in people with the lowest educational attainment (coefficient: 0.252 (90% credible intervals 0.003, 0.486)) and in low levels of occupation (coefficient: 0.109 (-0.069, 0.288)). Those with no qualification had, on average, a 5.7% (0.1%, 11.1%) higher dietary sodium intake than the reference group. Compared to 2000-2001 the gradient of dietary sodium intake from south to north was attenuated after adjustments for confounders. Estimated dietary sodium consumption from food sources (not accounting for discretionary sources) was reduced by 366 mg of sodium (∼0.9 g of salt) per day during the 10-year period, likely the effect of national salt reduction initiatives.

CONCLUSIONS

Social inequalities in salt intake have not seen a reduction following the national salt reduction programme and still explain more than 5% of salt intake between more and less affluent groups. Understanding the socioeconomic pattern of salt intake is crucial to reduce inequalities. Efforts are needed to minimise the gap between socioeconomic groups for an equitable delivery of cardiovascular prevention.

Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study

BACKGROUND

Countries have agreed to reduce premature mortality (defined as the probability of dying between the ages of 30 years and 70 years) from four main non-communicable diseases (NCDs)--cardiovascular diseases, chronic respiratory diseases, cancers, and diabetes--by 25% from 2010 levels by 2025 (referred to as 25×25 target). Targets for selected NCD risk factors have also been agreed on. We estimated the contribution of achieving six risk factor targets towards meeting the 25×25 mortality target.

METHODS

We estimated the impact of achieving the targets for six risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) on NCD mortality between 2010 and 2025. Our methods accounted for multi-causality of NCDs and for the fact that when risk factor exposure increases or decreases, the harmful or beneficial effects on NCDs accumulate gradually. We used data for risk factor and mortality trends from systematic analyses of available country data. Relative risks for the effects of individual and multiple risks, and for change in risk after decreases or increases in exposure, were from re-analyses and meta-analyses of epidemiological studies.

FINDINGS

If risk factor targets are achieved, the probability of dying from the four main NCDs between the ages of 30 years and 70 years will decrease by 22% in men and by 19% in women between 2010 and 2025, compared with a decrease of 11% in men and 10% in women under the so-called business-as-usual trends (ie, projections based on current trends with no additional action). Achieving the risk factor targets will delay or prevent more than 37 million deaths (16 million in people aged 30-69 years and 21 million in people aged 70 years or older) from the main NCDs over these 15 years compared with a situation of rising or stagnating risk factor trends. Most of the benefits of achieving the risk factor targets, including 31 million of the delayed or prevented deaths, will be in low-income and middle-income countries, and will help to reduce the global inequality in premature NCD mortality. A more ambitious target on tobacco use (a 50% reduction) will almost reach the target in men (>24% reduction in the probability of death), and enhance the benefits to a 20% reduction in women.

INTERPRETATION

If the agreed risk factor targets are met, premature mortality from the four main NCDs will decrease to levels that are close to the 25×25 target, with most of these benefits seen in low-income and middle-income countries. On the basis of mortality benefits and feasibility, a more ambitious target than currently agreed should be adopted for tobacco use.

FUNDING

UK MRC.

Urinary sodium excretion and dietary sources of sodium intake in Chinese postmenopausal women with prehypertension

Background

Reducing salt intake in communities is one of the most effective and affordable public health strategies to prevent hypertension, stroke and renal disease. The present study aimed to determine the sodium intake in Hong Kong Chinese postmenopausal women and identify the major food sources contributing to sodium intake and urine excretion.

Methods

This was a cross-sectional study among 655 Chinese postmenopausal women with prehypertension who were screened for a randomized controlled trial. Data collection included 24 h urine collection for the measurement of sodium, potassium and creatinine, 3-day dietary records, anthropometric measures and questionnaire survey on demographic data and dietary habits.

Results

The average salt intake estimated from urinary excretion was 7.8±3.2 g/d with 82.1% women above WHO recommendation of 5 g/day. Food groups as soup (21.6%), rice and noodles (13.5%), baked cereals (12.3%), salted/preserved foods (10.8%), Chinese dim sum (10.2%) and sea foods (10.1%) were the major contributors of non-discretionary salt. Discretionary salt use in cooking made a modest contribution to overall intake. Vegetable and fruit intake, age, sodium intake from salted foods, sea foods and soup were the independent determinants of urinary sodium excretion.

Conclusions

Our data revealed a significant room for reduction of the sodium intake. Efforts to reduce sodium from diets in Hong Kong Chinese postmenopausal women should focus on both processed foods and discretionary salt during cooking. Sodium reduction in soup and increase in fruit intake would be potentially effective strategy for reducing sodium.

Current salt reduction policies across gradients of inequality-adjusted human development in the WHO European region: minding the gaps

OBJECTIVE

To assess current salt reduction policies in countries of the WHO European Region against the backdrop of varying levels of human development adjusted for income, education and health (longevity) inequalities.

DESIGN

Population-based, cross-sectional study, with data gathered through systematic review of relevant databases and supplementary information provided by WHO Nutrition Counterparts.

SETTING

Member States of the WHO European Region.

SUBJECTS

Inequality-adjusted Human Development Index scores were analysed against assessed levels of development and implementation of national nutrition policies and initiatives targeting population-level salt reduction.

RESULTS

Within the WHO European Region, Inequality-adjusted Human Development Index values among countries with no existing salt reduction initiatives (mean 0·643 (se 0·022)) were significantly lower than among those with either partially implemented/planned salt initiatives (mean 0·766 (se 0·017), P < 0·001) or fully implemented salt initiatives (mean 0·780 (se 0·021), P < 0·001).

CONCLUSIONS

Where salt reduction strategies are implemented as an integral part of national policy, outcomes have been promising. However, low- and middle-income countries may face severe resource constraints that keep them from emulating more comprehensive strategies pursued in high-income countries. Care must be taken to ensure that gaps are not inadvertently widened by monitoring differential policy impacts of salt policies, particularly regarding trade flows.

Cross-sectional survey of salt content in cheese: a major contributor to salt intake in the UK

OBJECTIVE

To investigate the salt (sodium chloride) content in cheese sold in UK supermarkets.

STUDY DESIGN

We carried out a cross-sectional survey in 2012, including 612 cheeses available in UK supermarkets.

METHODS

The salt content (g/100 g) was collected from product packaging and nutrient information panels of cheeses available in the top seven retailers.

RESULTS

Salt content in cheese was high with a mean (±SD) of 1.7±0.58 g/100 g. There was a large variation in salt content between different types of cheeses and within the same type of cheese. On average, halloumi (2.71±0.34 g/100 g) and imported blue cheese (2.71±0.83 g/100 g) contained the highest amounts of salt and cottage cheese (0.55±0.14 g/100 g) contained the lowest amount of salt. Overall, among the 394 cheeses that had salt reduction targets, 84.5% have already met their respective Department of Health 2012 salt targets. Cheddar and cheddar-style cheese is the most popular/biggest selling cheese in the UK and has the highest number of products in the analysis (N=250). On average, salt level was higher in branded compared with supermarket own brand cheddar and cheddar-style products (1.78±0.13 vs 1.72±0.14 g/100 g, p<0.01). Ninety per cent of supermarket own brand products met the 2012 target for cheddar and cheddar-style cheese compared with 73% of branded products (p=0.001).

CONCLUSIONS

Salt content in cheese in the UK is high. There is a wide variation in the salt content of different types of cheeses and even within the same type of cheese. Despite this, 84.5% of cheeses have already met their respective 2012 targets. These findings demonstrate that much larger reductions in the amount of salt added to cheese could be made and more challenging targets need to be set, so that the UK can continue to lead the world in salt reduction.

Cost-effectiveness analysis of salt reduction policies to reduce coronary heart disease in Syria, 2010-2020

OBJECTIVES

This study presents a cost-effectiveness analysis of salt reduction policies to lower coronary heart disease in Syria.

METHODS

Costs and benefits of a health promotion campaign about salt reduction (HP); labeling of salt content on packaged foods (L); reformulation of salt content within packaged foods (R); and combinations of the three were estimated over a 10-year time frame. Policies were deemed cost-effective if their cost-effectiveness ratios were below the region's established threshold of $38,997 purchasing power parity (PPP). Sensitivity analysis was conducted to account for the uncertainty in the reduction of salt intake.

RESULTS

HP, L, and R+HP+L were cost-saving using the best estimates. The remaining policies were cost-effective (CERs: R=$5,453 PPP/LYG; R+HP=$2,201 PPP/LYG; R+L=$2,125 PPP/LYG). R+HP+L provided the largest benefit with net savings using the best and maximum estimates, while R+L was cost-effective with the lowest marginal cost using the minimum estimates.

CONCLUSIONS

This study demonstrated that all policies were cost-saving or cost effective, with the combination of reformulation plus labeling and a comprehensive policy involving all three approaches being the most promising salt reduction strategies to reduce CHD mortality in Syria.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

The role of law and governance reform in the global response to non-communicable diseases

Addressing non-communicable diseases ("NCDs") and their risk-factors is one of the most powerful ways of improving longevity and healthy life expectancy for the foreseeable future - especially in low- and middle-income countries. This paper reviews the role of law and governance reform in that process. We highlight the need for a comprehensive approach that is grounded in the right to health and addresses three aspects: preventing NCDs and their risk factors, improving access to NCD treatments, and addressing the social impacts of illness. We highlight some of the major impediments to the passage and implementation of laws for the prevention and control of NCDs, and identify important practical steps that governments can take as they consider legal and governance reforms at country level.We review the emerging global architecture for NCDs, and emphasise the need for governance structures to harness the energy of civil society organisations and to create a global movement that influences the policy agenda at the country level. We also argue that the global monitoring framework would be more effective if it included key legal and policy indicators. The paper identifies priorities for technical legal assistance in implementing the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. These include high-quality legal resources to assist countries to evaluate reform options, investment in legal capacity building, and global leadership to respond to the likely increase in requests by countries for technical legal assistance. We urge development agencies and other funders to recognise the need for development assistance in these areas. Throughout the paper, we point to global experience in dealing with HIV and draw out some relevant lessons for NCDs.

[Factors associated with the addition of salt to prepared food]

The scope of this research was to investigate the potential differences between men and women in the addition of salt to prepared food. The study included 47,557 individuals aged 18 to 64 participating in the Risk and Protection Factors for Chronic Disease Surveillance System by Telephone Interview carried out in 26 Brazilian state capitals and the Federal District in 2006. Differences between men and women were tested by the chi-square test and the association magnitudes between the dependent and independent variables were estimated by the Odds Ratio obtained by Multiple Logistic Regression analysis. The prevalence of the addition of salt to prepared food was 8.3%, being higher among men (9,8% vs 6,9%, p < 0.01). After adjustment, the addition of salt to prepared food was higher in individuals with self-rated fair to poor health, reporting cardiovascular disease and living in the North of Brazil. Hypertensive individuals reported addition of less salt to prepared food. Educational level was not associated with salt usage. Men add more salt than women. Public health policies aimed at reducing salt intake by the population should take into account the gender differences in salt intake and the factors that contribute to such differences.

Promoting cardiovascular health worldwide: strategies, challenges, and opportunities

Cardiovascular disease is the leading cause of death in the world, affecting not only industrialized but, above all, low- and middle-income countries, where it has overtaken infectious diseases as the first cause of death and its impact threatens social and economic development. The increased prevalence of cardiovascular disease in recent years together with projected mortality for the coming decades constitute an irrefutable argument for the urgent implementation of well-planned interventions to control the pandemic of cardiovascular diseases, especially in the more economically deprived countries. The combination of behavioral, social, environmental, and biological factors, and others related to health care systems, that contribute to the development of cardiovascular diseases requires a multi-sector strategy that promotes a healthy lifestyle, reduces cardiovascular risk factors, and cuts mortality and morbidity through quality health care services. These proposals should be guided by leaders in the scientific community, government, civil society, private sector, and local communities.

Development and validation of a salt knowledge questionnaire

OBJECTIVE

Initiatives promoting the reduction of high-salt food consumption by consumers need to be partly based on current levels of salt knowledge in the population. However, to date there is no validated salt knowledge questionnaire that could be used to assess population knowledge about dietary salt (i.e. salt knowledge). Therefore, the aim of the present study was to develop and validate a salt knowledge questionnaire.

DESIGN

A cross-sectional study was conducted on an online web survey platform using convenience, snowball sampling. The survey questionnaire was evaluated for content and face validity before being administered to the respondents.

SETTING

Online survey.

SUBJECTS

A total of forty-one nutrition experts, thirty-two nutrition students and thirty-six lay people participated in the study.

RESULTS

Item analyses were performed to evaluate the psychometric properties of the test items. Twenty-five items were retained to form the final set of questions. The total scores of the experts were higher than those of the students and lay people (P < 0·05). The total salt knowledge score showed significant correlations with use of salt at the table (ρ = -0·197, P < 0·05) and inspection of the salt content in food products when shopping (ρ = 0·400; P < 0·01).

CONCLUSIONS

The questionnaire demonstrated sufficient evidence of construct validity and internal consistencies between the items. It is likely to be a useful tool for the evaluation and measurement of levels of salt knowledge in the general population.

Effectiveness of pharmacologic therapies on smoking cessation success: three years results of a smoking cessation clinic

BACKGROUND

Pharmacologic therapies have an important role in the success of interventions for smoking cessation. This study aims to determine the efficacy of several pharmacologic treatments in patients who applied to a smoking cessation clinic.

METHODS

This retrospective study includes 422 patients who presented to our smoking cessation clinic between January 2010 and June 2013, used the pharmacologic treatment as prescribed and completed the one-year follow-up period. All patients were assessed using the Fagerström Test for Nicotine Dependence (FTND) and received both behavioral therapy and pharmacotherapy. Patients' smoking status at one year was assessed by telephone interview.

RESULTS

The patients were 24.3% female (103/422) and 75.7% male (319/422) with a mean age of 38 ± 10 years. Patients were divided into three groups: varenicline (166 patients), bupropion (148 patients) and nicotine replacement therapy (108 patients).The smoking cessation rates of these groups were 32.5%, 23% and 52.8%, respectively, and were statistically significant (p > 0.001). The overall success rate was 35%. Further analysis revealed that pharmacologic therapy (p > 0.001) and gender (p = 0.01) were factors that showed statistically significant effects on smoking cessation rates. Males had higher success rates than females. The overall relapse rate was 21.6% and the bupropion group showed the highest relapse rate among treatment groups. Lack of determination emerged as the most important factor leading to relapse.

CONCLUSION

Nicotine replacement therapy was found to be more effective at promoting abstinence from smoking than other pharmacologic therapies.

Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study

BACKGROUND

There is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies.

METHODS/DESIGN

Intervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake.

DISCUSSION

Salt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.

Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control

BACKGROUND

This study uses data from the World Health Organization's Study on Global Ageing and Adult Health (SAGE) to examine patterns of hypertension prevalence, awareness, treatment and control for people aged 50 years and over in China, Ghana, India, Mexico, the Russian Federation and South Africa.

METHODS

The SAGE sample comprises of 35 125 people aged 50 years and older, selected randomly. Hypertension was defined as ≥140 mmHg (systolic blood pressure) or ≥90 mmHg (diastolic blood pressure) or by currently taking antihypertensives. Control of hypertension was defined as blood pressure below 140/90 mmHg on treatment. A person was defined as aware if he/she was hypertensive and self-reported the condition.

RESULTS

Prevalence rates in all countries are broadly comparable to those of developed countries (52.9%; range 32.3% in India to 77.9% in South Africa). Hypertension was associated with overweight/obesity and was more common in women, those in the lowest wealth quintile and in heavy alcohol consumers. Awareness was found to be low for all countries, albeit with substantial national variations (48.3%; range 23.3% in Ghana to 72.1% in the Russian Federation). This was also the case for control (10.2%; range 4.1% in Ghana to 14.1% India) and treatment efficacy (26.3%; range 17.4% in the Russian Federation to 55.2% in India). Awareness was associated with increasing age, being female and being overweight or obese. Effective control of hypertension was more likely in older people, women and in the richest quintile. Obesity was associated with poorer control.

CONCLUSIONS

The high rates of hypertension in low- and middle-income countries are striking. Levels of treatment and control are inadequate despite half those sampled being aware of their condition. Since cardiovascular disease is by far the largest cause of years of life lost in these settings, these findings emphasize the need for new approaches towards control of this major risk factor.

Understanding the patterns and trends of sodium intake, potassium intake, and sodium to potassium ratio and their effect on hypertension in China

BACKGROUND

Recent studies have shown inconsistent effects of sodium reduction, potassium intake, and the ratio of sodium to potassium (Na/K ratio) on hypertension and other cardiovascular diseases. Major gaps exist in knowledge regarding these issues in China.

OBJECTIVE

We analyzed the patterns and trends of dietary sodium intake, potassium intake, and the Na/K ratio and their relations with incident hypertension in China.

DESIGN

The China Health and Nutrition Survey cohort includes 16,869 adults aged 20-60 y from 1991 to 2009. Three consecutive 24-h dietary recalls and condiment and food weights provided detailed dietary data. Multinomial logistic regression models determined trends and patterns of sodium and potassium intake and the Na/K ratio. Models for survival-time data estimated the hazard of incident hypertension.

RESULTS

Sodium intake is decreasing but remains double the Institute of Medicine recommendations. Most sodium comes from added condiments. Adults in the central provinces have the highest sodium intake and the most rapid increase in hypertension. Potassium intake has increased slightly but is below half of the recommended amount. The Na/K ratio is significantly higher than the recommended amounts. Recent measurements of high sodium intake, low potassium intake, and high Na/K ratio have strong independent dose-response associations with incident hypertension.

CONCLUSIONS

Reducing sodium in processed foods, the major public health strategy in Western countries, may be less effective in China, where salt intake remains high. Replacing sodium with potassium in salt to control and prevent hypertension in China should be considered along with other public health and clinical prevention options.

Costs, benefits, and effectiveness of interventions for the prevention, treatment, and control of cardiovascular diseases and diabetes in Africa

If a combination of cost-effective health-care interventions and population-wide prevention interventions is implemented in a sustainable manner, a significant impact can be made on the cardiovascular disease and diabetes burden. Given the limited resources, weak health systems and competing health issues in Africa, the focus should be on interventions prioritized on the basis not only of cost effectiveness but also of affordability, feasibility and high impact. The Global Action Plan for prevention and control of noncommunicable diseases 2013-2020 identifies such a core set. Financing the effective delivery of this core set as part of the basic health care package through a strengthened health system is a pragmatic approach to address cardiovascular disease and diabetes in Africa. Cost of implementation of this core set of interventions represents an annual investment of under US$ 1 in low income countries, US$ 1.50 in lower middle income countries and US$ 3 in upper middle income countries.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries

Background

Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey.

Methods and Findings

Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey.

Conclusion

Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Drop the Salt! Assessing the impact of a public health advocacy strategy on Australian government policy on salt

OBJECTIVE

In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy.

DESIGN

A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney.

SUBJECTS

All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed.

RESULTS

Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods.

CONCLUSIONS

While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.

Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide

OBJECTIVES

To estimate global, regional (21 regions) and national (187 countries) sodium intakes in adults in 1990 and 2010.

DESIGN

Bayesian hierarchical modelling using all identifiable primary sources.

DATA SOURCES AND ELIGIBILITY

We searched and obtained published and unpublished data from 142 surveys of 24 h urinary sodium and 103 of dietary sodium conducted between 1980 and 2010 across 66 countries. Dietary estimates were converted to urine equivalents based on 79 pairs of dual measurements.

MODELLING METHODS

Bayesian hierarchical modelling used survey data and their characteristics to estimate mean sodium intake, by sex, 5 years age group and associated uncertainty for persons aged 20+ in 187 countries in 1990 and 2010. Country-level covariates were national income/person and composition of food supplies.

MAIN OUTCOME MEASURES

Mean sodium intake (g/day) as estimable by 24 h urine collections, without adjustment for non-urinary losses.

RESULTS

In 2010, global mean sodium intake was 3.95 g/day (95% uncertainty interval: 3.89 to 4.01). This was nearly twice the WHO recommended limit of 2 g/day and equivalent to 10.06 (9.88-10.21) g/day of salt. Intake in men was ∼10% higher than in women; differences by age were small. Intakes were highest in East Asia, Central Asia and Eastern Europe (mean >4.2 g/day) and in Central Europe and Middle East/North Africa (3.9-4.2 g/day). Regional mean intakes in North America, Western Europe and Australia/New Zealand ranged from 3.4 to 3.8 g/day. Intakes were lower (<3.3 g/day), but more uncertain, in sub-Saharan Africa and Latin America. Between 1990 and 2010, modest, but uncertain, increases in sodium intakes were identified.

CONCLUSIONS

Sodium intakes exceed the recommended levels in almost all countries with small differences by age and sex. Virtually all populations would benefit from sodium reduction, supported by enhanced surveillance.

Prevalence of obesity, tobacco use, and alcohol consumption by socioeconomic status among six communities in Nicaragua

OBJECTIVE

To describe the prevalence of noncommunicable disease (NCD) risk factors (overweight/obesity, tobacco smoking, and alcohol consumption) and identify correlations between these and sociodemographic characteristics in western and central Nicaragua.

METHODS

This was a cross-sectional study of 1 355 participants from six communities in Nicaragua conducted in September 2007-July 2009. Demographic and NCD risk-related health behavior information was collected from each individual, and their body mass index (BMI), blood pressure, diabetes status, and renal function were assessed. Data were analyzed using descriptive statistics, bivariate analyses, and (non-stratified and stratified) logistic regression models.

RESULTS

Of the 1 355 study participants, 22.0% were obese and 55.1% were overweight/obese. Female sex, higher income, and increasing age were significantly associated with obesity. Among men, lifelong urban living correlated with obesity (Odds Ratio [OR] = 4.39, 1.18-16.31). Of the total participants, 31.3% reported ever smoking tobacco and 47.7% reported ever drinking alcohol. Both tobacco smoking and alcohol consumption were strikingly more common among men (OR = 13.0, 8.8-19.3 and 15.6, 10.7-22.6, respectively) and lifelong urban residents (OR = 2.42, 1.31-4.47 and 4.10, 2.33-7.21, respectively).

CONCLUSIONS

There was a high prevalence of obesity/overweight across all income levels. Women were much more likely to be obese, but men had higher rates of tobacco and alcohol use. The rising prevalence of NCD risk factors among even the poorest subjects suggests that an epidemiologic transition in underway in western and central Nicaragua whereby NCD prevalence is shifting to all segments of society. Raising awareness that health clinics can be used for chronic conditions needs to be priority.

Cigarettes become a dangerous product: tobacco in the rearview mirror, 1952-1965

Tobacco control's unparalleled success comes partly from advocates broadening the focus of responsibility beyond the smoker to include industry and government. To learn how this might apply to other issues, we examined how early tobacco control events were framed in news, legislative testimony, and internal tobacco industry documents. Early debate about tobacco is stunning for its absence of the personal responsibility rhetoric prominent today, focused instead on the health harms from cigarettes. The accountability of government, rather than the industry or individual smokers, is mentioned often; solutions focused not on whether government had a responsibility to act, but on how to act. Tobacco lessons can guide advocates fighting the food and beverage industry, but must be reinterpreted in current political contexts.